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New York State Patient-Centered Medical Home
(NYS PCMH) Recognition Program

The National Committee for Quality Assurance (NCQA), the creator of the nation’s leading patient-centered medical home (PCMH) program, collaborated with the New York State Department of Health (NYSDOH) to develop a customized PCMH Recognition Program that supports the state’s initiative to improve primary care through the medical home model and promote the Triple Aim: better health, lower costs and better patient experience. 

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If you aren’t currently recognized by NCQA, contact us for more information. If you are currently recognized and have questions about NYS PCMH, submit them through My NCQA.  

Why PCMH? 

PCMH is a care delivery model where the primary care team, with the involvement of the patient (and family, when appropriate), is responsible for managing the full spectrum of health care needs, coordinating with clinicians in other settings when care cannot be provided in the primary care setting.  

The PCMH model emphasizes care coordination, population health, evidence-based guidelines and effective use of HIT to meet the patient’s needs. New York State PCMH (NYS PCMH) Recognition helps practices put in place the structure, systems and processes to be effective in this model. 

 The NYS PCMH model helps practices:  

  • Improve patient-centered access and patient experience. 
  • Perform comprehensive health assessments to identify patient needs. 
  • Deliver better preventive care such as immunizations and cancer screenings. 
  • Prioritize comprehensive care management to keep chronic conditions under control. 
  • Coordinate with other clinicians involved in patient care and close referral loops to improve continuity and avoid gaps. 
  • Identify patients who require recommended interventions and patients who need medication monitoring. 

Additional Benefits for Practices

To support the efforts required in transforming New York practices to this new, exclusive model of patient care, NYSDOH provides the following resources: 

Recognition at no cost to practices. NYSDOH covers the first year NYS PCMH Recognition fee or the first NYS PCMH Annual Reporting fee. The practice is responsible for paying their Annual Reporting fee each year after earning NYS PCMH Recognition.

Transformation assistance. New York state contracted with 15 organizations that specialize in NYS PCMH transformation and are available at no cost to participating practices. These entities provide step-by-step assistance in managing the transformation process and support the efforts of improving the patient experience. For more information, or to find a Transformation Assistance Contractor, visit ncqa.org/ta

Enhanced reimbursement opportunities. Practices that participate in NYS PCMH transformation may be eligible to receive supplemental payments through State programs such as the Medicaid PCMH Incentive Program. In addition, NYSDOH is engaged regionally with commercial payers to implement voluntary, multi-payer value-based payment (VBP) arrangements to support practices that have not had these opportunities through previous transformation efforts. Many of these models and eligibility to participate will depend on practices achieving NYS PCMH recognition. 

This all leads to lower health care costs, improved patient experience and better health outcomes

NYS PCMH Program Overview 

The NYS PCMH Recognition Program features six concepts that make up a medical home. Underlying these concepts are criteria (activities for which a practice must demonstrate adequate performance to obtain NYS PCMH Recognition) developed from evidence-based guidelines and best practices. 

To earn recognition through NYS PCMH, the practice must meet all 40 core criteria and 12 NYS required criteria (with elective credit), earning a total of 25 credits in elective criteria across 5 of 6 concepts (16-19 credits are earned by the required NYS criteria, crossing all 6 Concepts). Which of the remaining 6-9 credits of elective criteria you complete are up to the practice.

The NYS PCMH Standards and Guidelines document details program requirements. 

How to Enroll in NYS PCMH 

A practice downloads the Standards and Guidelines document, which contains the requirements for the program, and works with a Transformation Assistance Contractor to begin applying the standards to the practice. The entire recognition process is managed through Quality Performance Assessment Support System (Q-PASS), a user-friendly, online platform that allows for the upload of documentation, tracking of progress and management of practice sites and clinicians. 

 Paths to enroll for practices: